SUMMARY Background and AimThe potential prognostic value for survival of nutritional status in cirrhotics after adjusting Child-Pugh classification and Model for EndStage Liver Disease has not been evaluated.

Background and Purpose The Centers for Medicare and Medicaid Services (CMS) proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of post-stroke readmissions that is potentially preventable is unknown. Methods Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged ≥65 years discharged alive with a primary diagnosis of ischemic stroke (ICD-9-CM 433, 434, 436) between 12/2005-11/2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality (AHRQ). National, hospital-level, and regional preventable readmission rates were estimated. A random-effects logistic regression model was also used to determine patient-level factors associated with preventable readmissions. Results Among 307,887 ischemic stroke discharges, 44,379 (14.4%) were readmitted within 30 days; 5,322 (1.7% of all discharges) were the result of a preventable cause (e.g., pneumonia) and 39,057 (12.7%) were for other reasons (e.g., cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions. Conclusions Based on the AHRQ Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the AHRQ measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and reduce costs should target these high-risk patients.

“As the old technologies become automatic and invisible, we find ourselves more concerned with fighting or embracing what’s new”—Dennis Baron, From Pencils to Pixels: The Stage of Literacy Technologies Popular music is firmly rooted within realist practice, or what has been called the "culture of authenticity" associated with modernism. As Lawrence Grossberg notes, the accelleration of the rate of change in modern life caused, in post-war youth culture, an identity crisis or "lived contradiction" that gave rock (particularly) and popular music (generally) a peculiar position in regard to notions of authenticity. Grossberg places rock's authenticity within the "difference" it maintains from other cultural forms, and notes that its difference "can be justified aesthetically or ideologically, or in terms of the social position of the audiences, or by the economics of its production, or through the measure of its popularity or the statement of its politics" (205-6). Popular music scholars have not adequately addressed issues of authenticity and individuality. Two of the most important questions to be asked are: How is authenticity communicated in popular music? What is the site of the interpretation of authenticity? It is important to ask about sound, technology, about the attempt to understand the ideal and the image, the natural and artificial. It is these that make clear the strongest connections between popular music and contemporary culture. Popular music is a particularly appropriate site for the study of authenticity as a cultural category, for several reasons. For one thing, other media do not follow us, as aural media do, into malls, elevators, cars, planes. Nor do they wait for us, as a tape player paused and ready to play. What is important is not that music is "everywhere" but, to borrow from Vivian Sobchack, that it creates a "here" that can be transported anywhere. In fact, we are able to walk around enveloped by a personal aural environment, thanks to a Sony Walkman.1 Also, it is more difficult to shut out the aural than the visual. Closing one's ears does not entirely shut out sound. There is, additionally, the sense that sound and music are interpreted from within, that is, that they resonate through and within the body, and as such engage with one's self in a fashion that coincides with Charles Taylor's claim that the "ideal of authenticity" is an inner-directed one. It must be noted that authenticity is not, however, communicated only via music, but via text and image. Grossberg noted the "primacy of sound" in rock music, and the important link between music, visual image, and authenticity: Visual style as conceived in rock culture is usually the stage for an outrageous and self-conscious inauthenticity... . It was here -- in its visual presentation -- that rock often most explicitly manifested both an ironic resistance to the dominant culture and its sympathies with the business of entertainment ... . The demand for live performance has always expressed the desire for the visual mark (and proof) of authenticity. (208) But that relationship can also be reversed: Music and sound serve in some instances to provide the aural mark and proof of authenticity. Consider, for instance, the "tear" in the voice that Jensen identifies in Hank Williams's singing, and in that of Patsy Cline. For the latter, voicing, in this sense, was particularly important, as it meant more than a singing style, it also involved matters of self-identity, as Jensen appropriately associates with the move of country music from "hometown" to "uptown" (101). Cline's move toward a more "uptown" style involved her visual image, too. At a significant turning point in her career, Faron Young noted, Cline "left that country girl look in those western outfits behind and opted for a slicker appearance in dresses and high fashion gowns" (Jensen 101). Popular music has forged a link with visual media, and in some sense music itself has become more visual (though not necessarily less aural) the more it has engaged with industrial processes in the entertainment industry. For example, engagement with music videos and film soundtracks has made music a part of the larger convergence of mass media forms. Alongside that convergence, the use of music in visual media has come to serve as adjunct to visual symbolisation. One only need observe the increasingly commercial uses to which music is put (as in advertising, film soundtracks and music videos) to note ways in which music serves image. In the literature from a variety of disciplines, including communication, art and music, it has been argued that music videos are the visualisation of music. But in many respects the opposite is true. Music videos are the auralisation of the visual. Music serves many of the same purposes as sound does generally in visual media. One can find a strong argument for the use of sound as supplement to visual media in Silverman's and Altman's work. For Silverman, sound in cinema has largely been overlooked (pun intended) in favor of the visual image, but sound is a more effective (and perhaps necessary) element for willful suspension of disbelief. One may see this as well in the development of Dolby Surround Sound, and in increased emphasis on sound engineering among video and computer game makers, as well as the development of sub-woofers and high-fidelity speakers as computer peripherals. Another way that sound has become more closely associated with the visual is through the ongoing evolution of marketing demands within the popular music industry that increasingly rely on visual media and force image to the front. Internet technologies, particularly the WorldWideWeb (WWW), are also evidence of a merging of the visual and aural (see Hayward). The development of low-cost desktop video equipment and WWW publishing, CD-i, CD-ROM, DVD, and other technologies, has meant that visual images continue to form part of the industrial routine of the music business. The decrease in cost of many of these technologies has also led to the adoption of such routines among individual musicians, small/independent labels, and producers seeking to mimic the resources of major labels (a practice that has become considerably easier via the Internet, as it is difficult to determine capital resources solely from a WWW site). Yet there is another facet to the evolution of the link between the aural and visual. Sound has become more visual by way of its representation during its production (a representation, and process, that has largely been ignored in popular music studies). That representation has to do with the digitisation of sound, and the subsequent transformation sound and music can undergo after being digitised and portrayed on a computer screen. Once digitised, sound can be made visual in any number of ways, through traditional methods like music notation, through representation as audio waveform, by way of MIDI notation, bit streams, or through representation as shapes and colors (as in recent software applications particularly for children, like Making Music by Morton Subotnick). The impetus for these representations comes from the desire for increased control over sound (see Jones, Rock Formation) and such control seems most easily accomplished by way of computers and their concomitant visual technologies (monitors, printers). To make computers useful tools for sound recording it is necessary to employ some form of visual representation for the aural, and the flexibility of modern computers allows for new modes of predominately visual representation. Each of these connections between the aural and visual is in turn related to technology, for as audio technology develops within the entertainment industry it makes sense for synergistic development to occur with visual media technologies. Yet popular music scholars routinely analyse aural and visual media in isolation from one another. The challenge for popular music studies and music philosophy posed by visual media technologies, that they must attend to spatiality and context (both visual and aural), has not been taken up. Until such time as it is, it will be difficult, if not impossible, to engage issues of authenticity, because they will remain rootless instead of situated within the experience of music as fully sensual (in some cases even synaesthetic). Most of the traditional judgments of authenticity among music critics and many popular music scholars involve space and time, the former in terms of the movement of music across cultures and the latter in terms of history. None rely on notions of the "situatedness" of the listener or musicmaker in a particular aural, visual and historical space. Part of the reason for the lack of such an understanding arises from the very means by which popular music is created. We have become accustomed to understanding music as manipulation of sound, and so far as most modern music production is concerned such manipulation occurs as much visually as aurally, by cutting, pasting and otherwise altering audio waveforms on a computer screen. Musicians no more record music than they record fingering; they engage in sound recording. And recording engineers and producers rely less and less on sound and more on sight to determine whether a recording conforms to the demands of digital reproduction.2 Sound, particularly when joined with the visual, becomes a means to build and manipulate the environment, virtual and non-virtual (see Jones, "Sound"). Sound & Music As we construct space through sound, both in terms of audio production (e.g., the use of reverberation devices in recording studios) and in terms of everyday life (e.g., perception of aural stimuli, whether by ear or vibration in the body, from points surrounding us), we centre it within experience. Sound combines the psychological and physiological. Audio engineer George Massenburg noted that in film theaters: You couldn't utilise the full 360-degree sound space for music because there was an "exit sign" phenomena [sic]. If you had a lot of audio going on in the back, people would have a natural inclination to turn around and stare at the back of the room. (Massenburg 79-80) However, he went on to say, beyond observations of such reactions to multichannel sound technology, "we don't know very much". Research in psychoacoustics being used to develop virtual audio systems relies on such reactions and on a notion of human hardwiring for stimulus response (see Jones, "Sense"). But a major stumbling block toward the development of those systems is that none are able to account for individual listeners' perceptions. It is therefore important to consider the individual along with the social dimension in discussions of sound and music. For instance, the term "sound" is deployed in popular music to signify several things, all of which have to do with music or musical performance, but none of which is music. So, for instance, musical groups or performers can have a "sound", but it is distinguishable from what notes they play. Entire music scenes can have "sounds", but the music within such scenes is clearly distinct and differentiated. For the study of popular music this is a significant but often overlooked dimension. As Grossberg argues, "the authenticity of rock was measured by its sound" (207). Visually, he says, popular music is suspect and often inauthentic (sometimes purposefully so), and it is grounded in the aural. Similarly in country music Jensen notes that the "Nashville Sound" continually evoked conflicting definitions among fans and musicians, but that: The music itself was the arena in and through which claims about the Nashville Sound's authenticity were played out. A certain sound (steel guitar, with fiddle) was deemed "hard" or "pure" country, in spite of its own commercial history. (84) One should, therefore, attend to the interpretive acts associated with sound and its meaning. But why has not popular music studies engaged in systematic analysis of sound at the level of the individual as well as the social? As John Shepherd put it, "little cultural theoretical work in music is concerned with music's sounds" ("Value" 174). Why should this be a cause for concern? First, because Shepherd claims that sound is not "meaningful" in the traditional sense. Second, because it leads us to re-examine the question long set to the side in popular music studies: What is music? The structural homology, the connection between meaning and social formation, is a foundation upon which the concept of authenticity in popular music stands. Yet the ability to label a particular piece of music "good" shifts from moment to moment, and place to place. Frith understates the problem when he writes that "it is difficult ... to say how musical texts mean or represent something, and it is difficult to isolate structures of musical creation or control" (56). Shepherd attempts to overcome this difficulty by emphasising that: Music is a social medium in sound. What [this] means ... is that the sounds of music provide constantly moving and complex matrices of sounds in which individuals may invest their own meanings ... [however] while the matrices of sounds which seemingly constitute an individual "piece" of music can accommodate a range of meanings, and thereby allow for negotiability of meaning, they cannot accommodate all possible meanings. (Shepherd, "Art") It must be acknowledged that authenticity is constructed, and that in itself is an argument against the most common way to think of authenticity. If authenticity implies something about the "pure" state of an object or symbol then surely such a state is connected to some "objective" rendering, one not possible according to Shepherd's claims. In some sense, then, authenticity is autonomous, its materialisation springs not from any necessary connection to sound, image, text, but from individual acts of interpretation, typically within what in literary criticism has come to be known as "interpretive communities". It is not hard to illustrate the point by generalising and observing that rock's notion of authenticity is captured in terms of songwriting, but that songwriters are typically identified with places (e.g. Tin Pan Alley, the Brill Building, Liverpool, etc.). In this way there is an obvious connection between authenticity and authorship (see Jones, "Popular Music Studies") and geography (as well in terms of musical "scenes", e.g. the "Philly Sound", the "Sun Sound", etc.). The important thing to note is the resultant connection between the symbolic and the physical worlds rooted (pun intended) in geography. As Redhead & Street put it: The idea of "roots" refers to a number of aspects of the musical process. There is the audience in which the musician's career is rooted ... . Another notion of roots refers to music. Here the idea is that the sounds and the style of the music should continue to resemble the source from which it sprang ... . The issue ... can be detected in the argument of those who raise doubts about the use of musical high-technology by African artists. A final version of roots applies to the artist's sociological origins. (180) It is important, consequently, to note that new technologies, particularly ones associated with the distribution of music, are of increasing importance in regulating the tension between alienation and progress mentioned earlier, as they are technologies not simply of musical production and consumption, but of geography. That the tension they mediate is most readily apparent in legal skirmishes during an unsettled era for copyright law (see Brown) should not distract scholars from understanding their cultural significance. These technologies are, on the one hand, "liberating" (see Hayward, Young, and Marsh) insofar as they permit greater geographical "reach" and thus greater marketing opportunities (see Fromartz), but on the other hand they permit less commercial control, insofar as they permit digitised music to freely circulate without restriction or compensation, to the chagrin of copyright enthusiasts. They also create opportunities for musical collaboration (see Hayward) between performers in different zones of time and space, on a scale unmatched since the development of multitracking enabled the layering of sound. Most importantly, these technologies open spaces for the construction of authenticity that have hitherto been unavailable, particularly across distances that have largely separated cultures and fan communities (see Paul). The technologies of Internetworking provide yet another way to make connections between authenticity, music and sound. Community and locality (as Redhead & Street, as well as others like Sara Cohen and Ruth Finnegan, note) are the elements used by audience and artist alike to understand the authenticity of a performer or performance. The lived experience of an artist, in a particular nexus of time and space, is to be somehow communicated via music and interpreted "properly" by an audience. But technologies of Internetworking permit the construction of alternative spaces, times and identities. In no small way that has also been the situation with the mediation of music via most recordings. They are constructed with a sense of space, consumed within particular spaces, at particular times, in individual, most often private, settings. What the network technologies have wrought is a networked audience for music that is linked globally but rooted in the local. To put it another way, the range of possibilities when it comes to interpretive communities has widened, but the experience of music has not significantly shifted, that is, the listener experiences music individually, and locally. Musical activity, whether it is defined as cultural or commercial practice, is neither flat nor autonomous. It is marked by ever-changing tastes (hence not flat) but within an interpretive structure (via "interpretive communities"). Musical activity must be understood within the nexus of the complex relations between technical, commercial and cultural processes. As Jensen put it in her analysis of Patsy Cline's career: Those who write about culture production can treat it as a mechanical process, a strategic construction of material within technical or institutional systems, logical, rational, and calculated. But Patsy Cline's recording career shows, among other things, how this commodity production view must be linked to an understanding of culture as meaning something -- as defining, connecting, expressing, mattering to those who participate with it. (101) To achieve that type of understanding will require that popular music scholars understand authenticity and music in a symbolic realm. Rather than conceiving of authenticity as a limited resource (that is, there is only so much that is "pure" that can go around), it is important to foreground its symbolic and ever-changing character. Put another way, authenticity is not used by musician or audience simply to label something as such, but rather to mean something about music that matters at that moment. Authenticity therefore does not somehow "slip away", nor does a "pure" authentic exist. Authenticity in this regard is, as Baudrillard explains concerning mechanical reproduction, "conceived according to (its) very reproducibility ... there are models from which all forms proceed according to modulated differences" (56). Popular music scholars must carefully assess the affective dimensions of fans, musicians, and also record company executives, recording producers, and so on, to be sensitive to the deeply rooted construction of authenticity and authentic experience throughout musical processes. Only then will there emerge an understanding of the structures of feeling that are central to the experience of music. Footnotes For analyses of the Walkman's role in social settings and popular music consumption see du Gay; Hosokawa; and Chen. It has been thus since the advent of disc recording, when engineers would watch a record's grooves through a microscope lens as it was being cut to ensure grooves would not cross over one into another. References Altman, Rick. "Television/Sound." Studies in Entertainment. Ed. Tania Modleski. Bloomington: Indiana UP, 1986. 39-54. Baudrillard, Jean. Symbolic Death and Exchange. London: Sage, 1993. Brown, Ronald. Intellectual Property and the National Information Infrastructure: The Report of the Working Group on Intellectual Property Rights. Washington, DC: U.S. Department of Commerce, 1995. Chen, Shing-Ling. "Electronic Narcissism: College Students' Experiences of Walkman Listening." Annual meeting of the International Communication Association. Washington, D.C. 1993. Du Gay, Paul, et al. Doing Cultural Studies. London: Sage, 1997. Frith, Simon. Sound Effects. New York: Pantheon, 1981. Fromartz, Steven. "Starts-ups Sell Garage Bands, Bowie on Web." Reuters newswire, 4 Dec. 1996. Grossberg, Lawrence. We Gotta Get Out of This Place. London: Routledge, 1992. Hayward, Philip. "Enterprise on the New Frontier." Convergence 1.2 (Winter 1995): 29-44. Hosokawa, Shuhei. "The Walkman Effect." Popular Music 4 (1984). Jensen, Joli. The Nashville Sound: Authenticity, Commercialisation and Country Music. Nashville, Vanderbilt UP, 1998. Jones, Steve. Rock Formation: Music, Technology and Mass Communication. Newbury Park, CA: Sage, 1992. ---. "Popular Music Studies and Critical Legal Studies" Stanford Humanities Review 3.2 (Fall 1993): 77-90. ---. "A Sense of Space: Virtual Reality, Authenticity and the Aural." Critical Studies in Mass Communication 10.3 (Sep. 1993), 238-52. ---. "Sound, Space & Digitisation." Media Information Australia 67 (Feb. 1993): 83-91. Marrsh, Brian. "Musicians Adopt Technology to Market Their Skills." Wall Street Journal 14 Oct. 1994: C2. Massenburg, George. "Recording the Future." EQ (Apr. 1997): 79-80. Paul, Frank. "R&B: Soul Music Fans Make Cyberspace Their Meeting Place." Reuters newswire, 11 July 1996. Redhead, Steve, and John Street. "Have I the Right? Legitimacy, Authenticity and Community in Folk's Politics." Popular Music 8.2 (1989). Shepherd, John. "Art, Culture and Interdisciplinarity." Davidson Dunston Research Lecture. Carleton University, Canada. 3 May 1992. ---. "Value and Power in Music." The Sound of Music: Meaning and Power in Culture. Eds. John Shepherd and Peter Wicke. Cambridge: Polity, 1993. Silverman, Kaja. The Acoustic Mirror. Bloomington: Indiana UP, 1988. Sobchack, Vivian. Screening Space. New York: Ungar, 1982. Young, Charles. "Aussie Artists Use Internet and Bootleg CDs to Protect Rights." Pro Sound News July 1995. Citation reference for this article MLA style: Steve Jones. "Seeing Sound, Hearing Image: 'Remixing' Authenticity in Popular Music Studies." M/C: A Journal of Media and Culture 2.4 (1999). [your date of access] <http://www.uq.edu.au/mc/9906/remix.php>. Chicago style: Steve Jones, "Seeing Sound, Hearing Image: 'Remixing' Authenticity in Popular Music Studies," M/C: A Journal of Media and Culture 2, no. 4 (1999), <http://www.uq.edu.au/mc/9906/remix.php> ([your date of access]). APA style: Steve Jones. (1999) Seeing Sound, Hearing Image: "Remixing" Authenticity in Popular Music Studies. M/C: A Journal of Media and Culture 2(4). <http://www.uq.edu.au/mc/9906/remix.php> ([your date of access]).

Background Recent studies of the Hiroshima and Nagasaki A-bomb survivors, together with some (but not all) cohorts exposed occupationally or medically to ionizing radiation, have found an increasing trend in mortality from non-malignant disease with increasing radiation dose. The aim of this study was to establish whether such a trend could be found in a large cohort of employees in the UK nuclear industry.Methods The cohort comprised 64 937 individuals ever employed at the study sites between 1946 and 2002, followed up to 2005; radiation exposures as measured by personal dosimeters (‘film badges’) were available for 42 426 individuals classified as ‘radiation workers’. Poisson regression models were used to investigate the relationship between excess mortality rates and cumulative radiation exposure, using both relative and additive risk models.Results The cohort shows a pronounced ‘healthy worker’ effect. Overall, socio-economic status as indicated by employment status has a greater influence on mortality than does radiation exposure status. For male radiation workers, there is an apparent dose response for mortality from circulatory system disease [P < 0.001, ERR = 0.65 (90% CI 0.36–0.98) Sv−1]. However there is evidence for inhomogeneity in the apparent dose response (P = 0.016), arising principally at cumulative doses in excess of 300 mSv, when the four categories of employment and radiation exposure status are examined separately.Conclusions We have found evidence for an association between mortality from non-cancer causes of death, particularly circulatory system disease, and external exposure to ionizing radiation in this cohort. However, the tentative nature of biological mechanisms that might explain such an effect at low chronic doses and the above inhomogeneities in apparent dose–response, mean that the results of our analysis are not consistent with any simple causal interpretation. Further work is required to explain these inhomogeneities, and on the possible role of factors associated with socio-economic status and shift working, before any further conclusions can be drawn.

Background and Purpose-Risk-standardized hospital readmission rates are used as publicly reported measures reflecting quality of care. Valid risk-standardized models adjust for differences in patient-level factors across hospitals. We conducted a systematic review of peer-reviewed literature to identify models that compare hospital-level poststroke readmission rates, evaluate patient-level risk scores predicting readmission, or describe patient and process-of-care predictors of readmission after stroke. Methods-Relevant studies in English published from January 1989 to July 2010 were identified using MEDLINE, PubMed, Scopus, PsycINFO, and all Ovid Evidence-Based Medicine Reviews. Authors of eligible publications reported readmission within 1 year after stroke hospitalization and identified Ն1 predictors of readmission in risk-adjusted statistical models. Publications were excluded if they lacked primary data or quantitative outcomes, reported only composite outcomes, or had Ͻ100 patients. Results-Of 374 identified publications, 16 met the inclusion criteria for this review. No model was specifically designed to compare risk-adjusted readmission rates at the hospital level or calculate scores predicting a patient's risk of readmission. The studies providing multivariable models of patient-level and/or process-of-care factors associated with readmission varied in stroke definitions, data sources, outcomes (all-cause and/or stroke-related readmission), durations of follow-up, and model covariates. Few characteristics were consistently associated with readmission. Conclusions-This review identified no risk-standardized models for comparing hospital readmission performance or predicting readmission risk after stroke. Patient-level and system-level factors associated with readmission were inconsistent across studies. The current literature provides little guidance for the development of risk-standardized models suitable for the public reporting of hospital-level stroke readmission performance. (Stroke. 2010;41:2525-2533.)